Last First Middle Degree

Provider Name______Last First Middle Degree Other Name Used______

Address______Street Apt# City State Zip

Telephone Number______

Date of Birth______

Place of Birth______

Email Address______

Social Security Number______

Citizenship______(if other than US provide documentation)

Languages Spoken______

1. Federal DEA

#______Expires______Schedules: ______

2. National Provider Identifier

(NPI)______NPI Login______NPI Password______

3. CAQH Login______CAQH Password______You may call 1-888-599-1771 to obtain this information if you do not know it.

4. Board Certification

Certifying Board______Certificate#______Year Certified______Expires______

If not certified have you been accepted by the board to take the examination and are you actively in the board certification process? Yes____ No____ If yes, indicate planned examination date ______

Have you ever taken and failed a certification examination? Yes____ No____ If yes, please explain______

5. Any other certifications or memberships? ______

6. Academic Appointments

Name______Rank______Department______Dates From (mm/yr)______to ______

7. Previous Clinical Rotations

Institution ______Dates (mm/yr) ______Address______Specialty______Preceptor______Preceptor telephone/email ______

8. Practicing Specialty

Primary______Secondary ______Essay Questions Please choose three of the five questions below to respond to. Answer in no more than 2 pages singe spaced and in 12 point font.

1. If you were the Dean of your nursing school, what specific three changes would you make, and why? What three attributes of your program would you absolutely not change, and why?

2. “Learning is not attained by chance, it must be sought for with ardor and attended to with diligence.”— Abigail Adams. Explain what you think the above statement means and how this applies to you.

3. Why do you think you will be an asset to Community Healthcare Network’s NP Fellowship?

4. What do you consider to be the single most important societal problem pertaining to healthcare? Why?

5. Briefly describe your short-term and long-term professional goals. Where do you see yourself in 10 years? Payment Please submit $50.00 payment via PayPal or mailing check to this address:

ATTENTION: CHN Nurse Nurse Practitioner Fellowship Program c/o Grace O’Shaughnessy 60 Madison Ave, 5th Floor New York, NY 10010

Applicants will not be processed until the application fee is received. Final Checklist

□ Fellowship Application □ CHN Application □ CV in month/year format □ Three (3) professional letters of recommendation if not board certified, two (2) if board certified o Dated, signed and addressed to Dr. Matthew Weissman, Chief Medical Officer o One (1) letter should be from a nursing education program, and one letter from employment. If more than 5 years post-graduation, one (1) letter should be from your current supervisor, and one (1) from your general employment. □ Essay Responses □ Copy of Diploma (BSN, MSN) **If not obtained, please submit transcripts □ Copy of License as Nurse Practitioner **Please put N/A if not graduated □ Copy of License as Registered Nurse □ Federal DEA license **Please put N/A if not graduated □ ANCC/AANP certification (or evidence of eligibility) **Please put N/A if not graduated □ Infection Control Certificate □ Two (2) passport photos □ Copy of state issued photo ID

Submit application and all materials to: [email protected]

Or mail to:

ATTENTION: CHN Nurse Practitioner Fellowship Program c/o Grace O’Shaughnessy 60 Madison Ave, 5th Floor New York, NY 10010